AASLD releases NAFLD practice guide for screening, treatment

July 19, 2017

The AASLD released a practice guidance document for the diagnosis and management of nonalcoholic fatty liver disease. The document is based on a formal review of recently published international literature, the American College of Physicians’ Manual for Assessing Health Practices and Designing Practice Guidelines, and the expertise of authors and independent reviewers.

“There is a paucity of data regarding the incidence of NAFLD in the general population. ... The incidence rates for NAFLD in the general population of Western countries are even less commonly reported [than those in Asian countries],” the researchers wrote. “In contrast to the incidence data, there is a significantly higher number of publications describing the prevalence of NAFLD in the general population.”

According to the practice guide, the estimated overall global prevalence of NAFLD diagnosed by imaging is about 25.24% (95% CI, 22.1-28.65). The highest prevalence is 31.79% from the Middle East (95% CI, 13.48-58.23) and 30.45% from South America (95% CI, 22.74-39.44), while the lowest prevalence is 13.48% from Africa (95% CI, 5.69-28.69).

The guide provides detailed analyses of screening and treatment procedures for NAFLD to help clinicians understand and implement the most recent evidence. The guide covers the following topics and recommendations:

While NAFLD indicates the lack of recent or regular alcohol consumption, a recent consensus meeting reviewing inconsistent data on alcohol consumption in NAFLD defined 21 standard drinks per week for men and 14 standard drinks per week for women as presenting an outstanding risk.

Unsuspected or incidental hepatic steatosis detected on imaging should lead to further assessment of related causes.

Routine screening is not typically recommended due to uncertainties in long-term benefits and cost-effectiveness, though initial evaluation of patients with suspected NAFLD should focus on competing comorbidities and coexisting liver disease.

Tools such as the NAFLD Fibrosis Score, vibration controlled transient elastography and magnetic resonance elastography are recommended for identifying patients with higher likelihood of having or developing advanced fibrosis or cirrhosis.

Liver biopsy is recommended in patients with NAFLD who are at increased risk for steatohepatitis or advanced fibrosis as determined by fibrosis score, elastography or competing etiologies.

Pharmacological treatments should generally be limited to patients with biopsy-proven nonalcoholic steatohepatitis and fibrosis.

Other potential interventions to decrease risk for NAFLD progression and to improve liver disease include lifestyle interventions, vitamin E administration in adults without diabetes, and bariatric surgery among patients with obesity.

Patients with NAFLD should be screen for gastroesophageal varices and patients with NAFLD-related cirrhosis should be considered for hepatocellular screening.

The guidance concludes with reviewed data and statements regarding pediatric NAFLD. According to the researchers, children with fatty liver who are not overweight or are very young should be tested for monogenic causes of chronic liver disease. Liver biopsy in children with suspected NALFD should be performed in those with unclear diagnosis, those with the possibility for multiple diagnoses, and those with suspected NASH. Intensive lifestyle modification improves aminotransferases and liver histology and is recommended as the first line of treatment. – by Talitha Bennett

Disclosure: The funding for the development of this Practice Guidance was provided by the American Association for the Study of Liver Diseases.

Editor's note: This item has been updated to include magnetic resonance elastography among the recommended tools for identifying NAFLD.

The AASLD released a practice guidance document for the diagnosis and management of nonalcoholic fatty liver disease. The document is based on a formal review of recently published international literature, the American College of Physicians’ Manual for Assessing Health Practices and Designing Practice Guidelines, and the expertise of authors and independent reviewers.

“There is a paucity of data regarding the incidence of NAFLD in the general population. ... The incidence rates for NAFLD in the general population of Western countries are even less commonly reported [than those in Asian countries],” the researchers wrote. “In contrast to the incidence data, there is a significantly higher number of publications describing the prevalence of NAFLD in the general population.”

According to the practice guide, the estimated overall global prevalence of NAFLD diagnosed by imaging is about 25.24% (95% CI, 22.1-28.65). The highest prevalence is 31.79% from the Middle East (95% CI, 13.48-58.23) and 30.45% from South America (95% CI, 22.74-39.44), while the lowest prevalence is 13.48% from Africa (95% CI, 5.69-28.69).

The guide provides detailed analyses of screening and treatment procedures for NAFLD to help clinicians understand and implement the most recent evidence. The guide covers the following topics and recommendations:

While NAFLD indicates the lack of recent or regular alcohol consumption, a recent consensus meeting reviewing inconsistent data on alcohol consumption in NAFLD defined 21 standard drinks per week for men and 14 standard drinks per week for women as presenting an outstanding risk.

Unsuspected or incidental hepatic steatosis detected on imaging should lead to further assessment of related causes.

Routine screening is not typically recommended due to uncertainties in long-term benefits and cost-effectiveness, though initial evaluation of patients with suspected NAFLD should focus on competing comorbidities and coexisting liver disease.

Tools such as the NAFLD Fibrosis Score, vibration controlled transient elastography and magnetic resonance elastography are recommended for identifying patients with higher likelihood of having or developing advanced fibrosis or cirrhosis.

Liver biopsy is recommended in patients with NAFLD who are at increased risk for steatohepatitis or advanced fibrosis as determined by fibrosis score, elastography or competing etiologies.

Pharmacological treatments should generally be limited to patients with biopsy-proven nonalcoholic steatohepatitis and fibrosis.

Other potential interventions to decrease risk for NAFLD progression and to improve liver disease include lifestyle interventions, vitamin E administration in adults without diabetes, and bariatric surgery among patients with obesity.

Patients with NAFLD should be screen for gastroesophageal varices and patients with NAFLD-related cirrhosis should be considered for hepatocellular screening.

The guidance concludes with reviewed data and statements regarding pediatric NAFLD. According to the researchers, children with fatty liver who are not overweight or are very young should be tested for monogenic causes of chronic liver disease. Liver biopsy in children with suspected NALFD should be performed in those with unclear diagnosis, those with the possibility for multiple diagnoses, and those with suspected NASH. Intensive lifestyle modification improves aminotransferases and liver histology and is recommended as the first line of treatment. – by Talitha Bennett

Disclosure: The funding for the development of this Practice Guidance was provided by the American Association for the Study of Liver Diseases.

Editor's note: This item has been updated to include magnetic resonance elastography among the recommended tools for identifying NAFLD.